Provider Demographics
NPI:1205136728
Name:VICKERS, IDA G (LPN)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:G
Last Name:VICKERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 MILLSTREAM RUN
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-1564
Mailing Address - Country:US
Mailing Address - Phone:216-533-3592
Mailing Address - Fax:
Practice Address - Street 1:817 MILLSTREAM RUN
Practice Address - Street 2:
Practice Address - City:MACEDONIA
Practice Address - State:OH
Practice Address - Zip Code:44056-1564
Practice Address - Country:US
Practice Address - Phone:216-533-3592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.140816-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse